Reactions 1164 - 11 Aug 2007

SBupivacaine

Neurotoxicity and arrhythmias following inadvertentintravascular administration in an elderly patient:case report

An 84-year-old woman, with stage IV peripheral arteryocclusive disorders, developed cardiac arrhythmias andneurotoxicity following inadvertent intravascularadministration of bupivacaine for pain therapy.

The woman, whose history included arterial hypertension,AV block, diabetes mellitus and amputation of her right thigh,received a lumbar epidural catheter. After catheter placementat L1/2 level, identification of the epidural space and negativeaspiration, a 0.5% bupivacaine 3mL test dose wasadministered. No signs of intravascular or intrathecal catheterplacements were evident within 5 minutes and two doses of0.25% bupivacaine 5mL were administered via the catheter. Apatient-controlled medication pump (PCA) containing 0.1%bupivacaine 500mL and fentanyl was then installed. Tenminutes after bupivacaine administration, signs of sensoryblock below L4 became evident. Within the following15 minutes, she reported a strong feeling of coldness,accompanied by strong shivering. She received clonidine, butshivering persisted for further 10 minutes, associated withprogressive central nervous excitation with confusion, motoricunrest, tetany of her hands and hyperventilation despiteadministration of supplementary oxygen via a facemask. At thesame time, she developed hypertension of 170/85mm Hg andtachycardia of up to 150 beats/min with progressiveventricular extrasystole and couplets.

Blood was aspirated through the catheter and PCA therapywas instantly discontinued; the woman had received acumulative bupivacaine dose of about 43mg. She receivedmidazolam and lidocaine. Her tachycardia persisted andextrasystole increased over the following 3 minutes. Propofoland a 20% lipid emulsion were administered. Extrasystole andtachycardia resolved within 15 minutes, her agitation andhyperventilation regressed, and she became responsive. Thecatheter was removed and she was transferred to an ICU. ECGfindings had returned to baseline, and she was awake andoriented when she was transferred to a ward 6 hours later.

Author comment: Even though bupivacaine plasmaconcentrations were not measured, a bupivacaineintoxication through intravascular administration is likely,considering the age and the weakened state of our patient,and her decreased total protein level of 54 g/L (albumin level33 g/L).Zimmer C, et al. Cardiotoxic and neurotoxic effects after accidental intravascularbupivacaine administration - therapy with lidocaine propofol and lipid emulison.Anaesthesist 56: 449-453, No. 5, May 2007 [German] - Germany 801090841

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Reactions 11 Aug 2007 No. 11640114-9954/10/1164-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved